Get Started With Xofigo
for Referring Providers
®
Xofigo® Access Services is here to help patients get started with
Xofigo® (radium Ra 223 dichloride) injection.
If requested, Xofigo Access Services will:
• Verify patients’ insurance benefits for Xofigo
• Provide information on prior authorization (PA) requirements and monitor the
status of the PA if you decide to submit it to the payer
• Provide information to facilitate follow-up patient care with Xofigo (opt-in required)
What happens once you refer patients to the physician administering Xofigo?
Xofigo Access Services will:
• Verify patient insurance benefits for the administering provider, if requested
• Provide information on PA requirements and monitor the status of the PA if the
administering provider decides to submit it to the payer
• Research and help eligible patients apply for patient assistance and copay/
coinsurance assistance as needed
• Confirm the treatment date(s) and time(s)
• Assist the administering provider in placing the order for Xofigo
Get Started With Xofigo
for Referring Providers
®
Get Started With the Xofigo Access Services Provider Referral Form
Please note that the Insurance Benefit Verification Request Form is for use by the
Referring Provider to request insurance benefit verification only
Provider Referral Form
For Use ONLY by Referring Providers
Xofigo® (radium Ra 223 dichloride) Injection
1. To request insurance benefit verification services, fax a completed Referral Form including the signed Patient Authorization (page 2 of this
form) to 1-855-963-4463. Or call Xofigo Access Services at 1-855-6XOFIGO (1-855-696-3446). Xofigo Access Services Access Counselors are
available from 9:00 am to 7:00 pm ET (M-F). You can also log onto the Xofigo Access Services Provider Portal 24 hours a day, 7 days a week
at XofigoAccessOnline.com.
2. Xofigo Access Services will call the payer(s) to conduct an insurance benefit verification and obtain any prior authorization requirements.
3. An Access Counselor will call your facility within 24-48 hours to discuss the results and fax you a summary of insurance benefits.
4. Use this form to request an insurance benefit verification only. This form may not be used to schedule Xofigo treatments or to place an
order for Xofigo.
The Patient
Authorization on the
following page must
be completed and
submitted with this form
to request insurance
benefit verification
services.
Referring Provider Information
Referring Provider Name:
Provider Specialty:
NPI#:
Tax ID#:
Practice Name:
If you know where
you will be referring
your patient for
treatment, please
let Xofigo Access
Services know
Practice Address:
City/State/Zip Code:
Primary Contact Name:
Title:
Phone:
Extension:
Fax:
Administering Provider Name:
Administering Facility Name:
Location (City/State/Zip Code):
Phone:
Patient Information
Patient Name:
Patient DOB:
Patient Address:
City/State/Zip Code:
Scheduled Treatment Date/Time:
ICD-10 Primary dx (check box):
Patient Phone:
C61
Other
OK to Contact?
ICD-10 Secondary dx:
C79.51
C79.52
Y
N
Other
Patient Insurance Information
Complete to request patient-specific benefit research for Xofigo:
Primary Insurance:
Policy #:
Phone:
Secondary Insurance:
Policy #:
Phone:
Xofigo Access
Services can contact
your patient to review
coverage for Xofigo
and patient copay
requirements
Physician Declaration
I verify that the information contained in this inquiry form is complete and accurate to the best of my knowledge. I understand that Bayer reserves the right
to modify or terminate Xofigo Access Services at any time and without notice. I understand that Bayer is not responsible for filing claims and that all final
decisions on diagnosis, the need for treatment, and the appropriateness of Xofigo for a particular patient rest with me as the patient’s provider. I agree to
abide by this certification throughout my participation in Xofigo Access Services.
I would like to receive updates from Xofigo Access Services regarding my patient’s treatment with Xofigo:
Physician Signature:
Y
N
Date:
Page 1 of 2
For a writeable PDF of this form, please visit www.xofigo-us.com
If you would like
to receive updates
regarding your patient’s
treatment with Xofigo,
please indicate that
preference here
Get Started With Xofigo
for Referring Providers
Patient Authorization for Xofigo® Access Services
Patient Authorization for Xofigo® Access Services
I authorize the use and/or disclosure of my private health information, described below, which may include “Protected Health Information”
or “PHI” as defined by the Health Insurance Portability and Accountability Act of 1996, as amended (“HIPAA”). In general terms, I
understand that Protected Health Information is health information that identifies me or that could reasonably be used to identify me. I
understand that this authorization is voluntary.
I authorize my healthcare providers that treat me or provide healthcare services to me, including my physicians and pharmacies, and my
health insurer(s) to share or disclose my name, address, and telephone number, along with certain medical records and insurance and
financial information with respect to my treatment; my eligibility for insurance or patient assistance; the coordination of my treatment,
including scheduling, ordering, and the receipt of my medication; and my participation in the Xofigo Access Services (the “Program”) to
Bayer and its agents. These agents include a company that is an administrative contractor that administers the Program, the supplier
which dispenses Xofigo, and a data analytics company which analyzes and produces reports of aggregated data (collectively “Bayer”). I
understand that certain healthcare providers may receive payment or other forms of remuneration from Bayer in connection with the use
and disclosure of my PHI as described in this authorization.
I allow the use and disclosure of my PHI for the following purposes: (1) to verify my financial or insurance information; (2) to ensure the
accuracy and completeness of the Program enrollment form; (3) to help with my reimbursement questions; (4) to see if I qualify for patient
assistance or copayment assistance or to refer me to, or determine my eligibility for, other programs, foundations, or alternate sources
of funding or coverage to help me with the costs of obtaining Xofigo; (5) to coordinate my Xofigo treatments; (6) to send me educational
materials or other Program information that may be of interest to me; (7) for commercial purposes, including to understand how Xofigo is
used across healthcare providers and other market research; (8) to manage supply and availability of Xofigo for my treatments; (9) to follow
up with my healthcare providers or myself with regard to any reported adverse event / product technical complaint / incident or other
safety related information; and (10) to comply with applicable law.
This authorization expires at the end of my participation in the Program or 3 years (or earlier if required by state law) from the date
of my signature, whichever comes first. I can withdraw (ie, take back) this authorization any time, except to the extent my healthcare provider
or health plan insurer has taken action in reliance on my authorization. I understand that if I revoke this authorization, it will not have any
effect on any actions my healthcare providers or my health plan may have taken before receiving the revocation, and will not affect Bayer’s
ability to use and disclose any information it has already received. I can withdraw this authorization by mailing a written request to Xofigo
Access Services, PO Box 220009, Charlotte, NC 28222-0009, or by faxing a request to 1-855-963-4463.
I also understand that persons or entities that receive my PHI under this authorization may not be required by privacy laws (such as the
HIPAA Privacy Rule) to protect the information and may share it with others without my permission, if permitted by laws applicable to them.
My healthcare providers and health plan insurer will not condition my medical treatment or its payment, insurance enrollment, or eligibility
for insurance benefits on my signing this form. However, if the information requested about me is not provided, Bayer will be unable to
determine my eligibility to participate in an available patient assistance program or copayment assistance program and, thus, I may be
unable to participate in these programs. I have read this authorization and/or had its contents read to me. I have had an opportunity to
ask questions about the uses and disclosures of PHI described above and all of my questions have been answered to my satisfaction. I
authorize the use and disclosure of my information as described in this form. I understand that I am entitled to receive a signed copy of
this authorization.
Print Patient’s or Patient Representative’s Name:
Date:
/
/
Patient’s or Patient Representative’s Signature:
Date:
/
/
If signed by the Patient’s Representative, include a description of the Representative’s relationship
to the Patient and such person’s authority to act for the Patient (eg, parent, guardian, etc)
© 2017 Bayer. All rights reserved.
BAYER, the Bayer Cross, Xofigo and the Xofigo Access Services logo are registered trademarks of Bayer.
PP-600-US-2626 01/17
Page 2 of 2
© 2017 Bayer. All rights reserved.
BAYER, the Bayer Cross, Xofigo and the Xofigo Access Services logo are registered trademarks of Bayer.
PP-600-US-2635 01/17
®